HomeMy WebLinkAboutSWG2017-00005 - SWG As-Built 1991 '°N AdSti:E L1(Q 'c 'P0 aWi1 paAlaa4
RECORD DRAWING (ASBIJILT) pg. 1 MASON COUNTY PUBLIC HEALTH
PARCEL IDENTIFICATION
Permit Number SW3 f -7 - 000 c).3 Assessor Parcel # 123 0 7-33 -()COCO
Applicant Name -Do J, GCot-1 E . Subdivision (NamelDivlBlock/Let)
Applicant Address (rvJ L6-1-L 5L3 Yam/ v� V4. o4 S.Gj-7 -30 z/J .K-t w
City, State, Zip tom. o 58 x 138 '1 5Z3 Installer Name IP, ,`De 7-1itf C
Site Address Designer Name IA, ' , H cc-O
INSTALLATION CHECKLIST
❑ Full System Insallation 10 Tank(s)Only ❑ Drairfield Only ['Repair ❑Cther
System Type Pretreatment Type
>5 ft.from foundation? - -- ❑ NA `® YES ❑ NO
>50 ft.from wells? - - ❑ -❑ ❑
Z >50 ft.from surface water? - - El -® ❑
Cleanout between building and tank? - - •- ❑ 0 .t
U Tank baffles present? - - ❑ ,® 0
F- 24"access risers over each compartment?- - 0 El 0
W Effluent fitter installed?- - 0 ❑ 21.
Septic tank size !5 35 gal Manufacturer 1.14/tf (— Hie/6-//-!> �,
o D-box water level and speed levelers used? - • El N/A El YES 0 NO
r
�OJ ❑ ❑Manifold/D-box accessible from surface?- - YJr
•m 2 Check valves installed? - •- I: I:Ina
� Transport Line Size Schedule/Class
3edrooms installed (check one) ❑ 2 ❑ 3 ❑4 ❑ 5 ❑6 ❑Commercial Other
>10 ft. from foundation?- - ❑ N/A ❑ YES ❑ NO
0 >100 ft. from wells? - - ❑ El
W >100 ft. from surface water? - - ❑ ❑ ❑
u.. >10 ft.from potable water lines?- - ❑ ❑ ❑
Z > 5 ft. from property lines and easements?- - ❑ ❑ ❑
Q ❑ El ❑
Q > 30 ft.from downgradient curtain/foundati► drins? - -
Drainfield level and observation ports p•-sent - - - ❑ ❑ ❑
❑ Graveless chambers or ❑ Clean gravel used? (check one)
Proper cover installed over drainfield?- •- ❑ ❑ ❑
Pump tank setbacks consistant with septic tank? - - ❑ NIA ❑ YES ❑ No
Pump tank size gal Manufacturer
Q 24" access riser(s) and accessible from slurface?- - ❑ ❑ ❑
F-a. Alarm or Control Panel Installed? - ❑ ❑ ❑
j Control Panel equipped with Timer/ ETM /COUntter- - - ❑ ❑ El
4. Pump installed in ❑ Bucket or ❑ On BI brr, ❑ Other
a• Pump Make/Model 0 Floats or 0 Transducer '
a_
a Tank draw down inlmi Pump capacity gpm Squirt Height fl.
Pump on time Pump off time Daily flow set at gpd
uceatcc 12,72C'5
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MCPH RECORD DRAWING (ASBUILT) pg. 2 Assessor Parcel# I2-307-33- Oc OCO
RECORD DRAWING
❑ Jraineld&manifold I l/1
orientation&layout 5 e. or--v'�c_lter! f o u�1Y1C�
widi r.ens:ons for
re-location.
153 5-6 L_ ?att.) 1—t od t l �'' -rn to
Trenchlbed
dimensions and T \ IO be_ I`ZeA G rC 5 ict
critical distances
within layout
Septictpurrp tank
placement
❑ Location of buildings
existing/proposed
❑ Observation ports,
clean-out locations,
&manifclds/d-boxes
❑ Location of wells,
surface water,roads,
&waterlines.
❑ Reserve area(s)
❑ North A-row
If the designer or installer feel the need for additional informatioricomments, it may be attached. /
Record drawing may also be on a seperate page attached. No. Pages Attached
CERTIFICATION OF INSTALLATION
INSTALLER DESIGNER
I certify that I installed the system in accordance with l certify that the system has been installed in accor-
the septic design stamped 'APPROVED"by Mason dance with the septic design stamped 'APPROVED"by
County Public Health and that any deviations shown Mason County Public Health and that any deviations
here have been cleared/approved by both the designer shown here have been cleared/approved by both
and Mason County Public Health and meet all State myself and Mason County Public Health and meet all
and Mason County Codes. State and Mason County Codes
I further certify that all information contained on this i further certify that all information contained on this
form an tta a Re i A Drawing is accurate. form and attached Record Drawing is accurate.
Signature of Installer Date ` cu� �
�dl y- G N 16 c
Printed Name of Signee 3, }c
.
MASON COUNTY PUBLIC HEALTH
�' 5101p25
The undersigned approves this installation Report and �O:ANTHONY ottiC'i oe iEao
f -P.S'n nF t .
Record Drawing on behalf of Mason County Public ��i iisi iairmaari ure -
Health: .t __1.=`63:- I
Signature of Environmental Health Specialist Date (designer's stamp, signature and date)
THIS FORM MAY BE SCANNED AND AVAILABLE FOR PUBLIC VIEW ON THE MASON COUNTY WEB SITE updatec 1227i20:5
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